What the 4895-64 is for
Under the Immunization of School Pupils Act, children attending primary or secondary school must be immunized against diphtheria, tetanus, polio, measles, mumps, rubella, meningococcal disease, pertussis and, for children born in 2010 or later, varicella. A child who isn’t fully immunized may not be allowed to attend school, and may be removed from school during an outbreak. The Statement of Medical Exemption removes the requirement for the vaccines it covers, when the child already has immunity or a vaccine would be detrimental to their health. It doesn’t record vaccines given. That goes in the immunization record reported to public health.
Who completes it
The physician or nurse practitioner completes and signs the statement. It has no parent section to sign, though the parent provides the pupil and school details and submits the form.
How to fill in sections 1 to 3
Section 1: pupil information
Name, date of birth, home address, school and grade. Public health matches the exemption to the child’s file with these, so use the name the school has on record.
Section 2: declaration
Write your name in the declaration, then work through the disease rows. For each disease, tick the basis: clinical diagnosis of prior disease, laboratory confirmation of immunity or prior disease, or contraindication detrimental to health. Then tick permanent or temporary, and for a temporary exemption give the from and to dates. Use the spaces below the table to define the evidence of immunity, such as the serology result and date, and to explain any contraindication.
Section 3: signature
Your name, business address, signature and date.
Common reasons it’s sent back
- A temporary exemption with no end date.
- Immunity claimed with no evidence described.
- A contraindication ticked with no explanation.
- Pupil details that don’t match the school record.
Submitting and who pays
Give the signed statement to the parent to submit to the local public health unit.